5 rd International Prof. Dr. Alireza Yalda Foundation in
Medical Sciences
Mechanical support of the heart in cardiogenic shock
6-10 October, 2014, Tehran, Iran
Abbas Ferdosi M.D.
Abbas Ferdosi, M.D.
Clinic of Cardiovascular and Thorax Surgery
Bad Rothenfelde, Germany
Oct. 2014

Pathophysiology of cardiogenic shock
Abbas Ferdosi M.D.
Oct. 2014

Abbas Ferdosi M.D.

Mortality has been decreased since
2003

< 75 J: 62% >>> 50%
 ≥ 75 J: 35% >>> 30%

Mortality female> male
Germany / year

280,000 myocardial infarctions

40% STEMI
112000

10% followed by CS
11000
Oct. 2014

Results
Schuechtermann Clinic
Bypass surgery in acute myocardial infarction
(<24h)
1/2004 - 09/2006 n = 321 (30-day mortality was 10%)
Myocardial infarction Without shock In shock n
30 days mortality
Age (years)
EF < 30%
211
1,4%
110
27%
67,3 (38-94) 66,5 (33-85)
14,2% 56,3%
Abbas Ferdosi M.D.
Oct. 2014

Mechanical Option
•
Intra Aortic Balloon Pump (IABP)
•
Extra Corporeal Membrane Oxygenation (ECMO)
•
Impella
Abbas Ferdosi M.D.
Oct. 2014

IABP
An investigation was undertaken to determine whether the blood supply through narrowed coronary arteries could be improved by delaying the arterial pressure wave so that it arrives in the coronary arteries during diastole.
In 1967 it was clinical introduction.
Currently 100.000 implantation per year.
Abbas Ferdosi M.D.
Oct. 2014

Intra-Aortic Balloon Pump (IABP) functional principle
Intra-Aortic Balloon-counterpulsation
Abbas Ferdosi M.D.
Oct. 2014

IABP functional principle
Abbas Ferdosi M.D.
Oct. 2014

IABP functional principle
Abbas Ferdosi M.D.
Oct. 2014

IABP functional principle
Diastole

Balloon inflates

Increased blood flow to coronaries
Systolie

Balloon deflates

Afterload is reduced

Increased forward blood flow
Abbas Ferdosi M.D.
Oct. 2014

Effects of IABP Therapy
Coronary perfusion
Stroke Volume
Ventricular Emptying
Cardiac output
LV Workload
Myocardial oxygen Demand
Abbas Ferdosi M.D.
Oct. 2014

IABP- Indication

Cardiogenic shock

Intractable angina pectoris

Low cardiac output after CABG

Support for diagnostic, percutaneous revascularisations and interventional procedures
 Others…
Abbas Ferdosi M.D.
Oct. 2014

Contraindication

Severe aortic regurgitation

Aortic dissection

Aneurysm of the abdominal or thoracica aorta

Severe calcific aorto- iliac disease or peripheral vascular
Abbas Ferdosi M.D.
Oct. 2014

Intraaortic Balloon Support for Myocardial Infarction with Cardiogenic Shock
Holger Thiele, M.D., Uwe Zeymer, M.D., Franz-Josef Neumann, M.D., Miroslaw Ferenc, M.D.,
Hans-Georg Olbrich, M.D October 10, 2012
CONCLUSIONS
The use of intraaortic balloon counterpulsation did not significantly reduce 30-day mortality in nupatients with cardiogenic shock complicating acute myocardial infarction for whom an early revascularization strategy was planned. (Funded by the
German Research Foundation and others; IABP-SHOCK II ClinicalTrials.gov mber, NCT00491036.)
Abbas Ferdosi M.D.
Oct. 2014

Extra Corporeal Membrane Oxygenation
(ECMO)
•
A form of extracorporeal life support where an external artificial circuit carries venous blood from the patient to an oxygenator where blood becomes enriched with oxygen and has carbon dioxide removed.
Abbas Ferdosi M.D.
Oct. 2014

ECMO
•
The blood is than returned to the patient via a central vein or an artery.
Abbas Ferdosi M.D.
Oct. 2014

ECMO cannulation
Abbas Ferdosi M.D.
Oct. 2014

ECMO cannulation
Abbas Ferdosi M.D.
Oct. 2014

ECMO function
•
Reduction of preload and afterload
•
Oxygenation of the blood
Abbas Ferdosi M.D.
Oct. 2014

ECMO indication

Cardiogenic shock

Post cardiotomy

Bridge to HTX/VAD

Graft failure

Myocarditis

ECMO-CPR
Abbas Ferdosi M.D.
Oct. 2014

ECMO Contraindications

Severe calcific aorto- iliac disease or peripheral vascular

Multi-Organ Failure

End-stage Disease
Abbas Ferdosi M.D.
Oct. 2014

ECMO complication

Peripheral arterial disease

Compartment syndrome
Abbas Ferdosi M.D.
Oct. 2014

Impella

The smallest heart pump in the world

9 Fr catheter, 12 Fr / 14Fr microaxial

Produces 2.5 / -4 L / min forward flow
Increases:
 coronary flow
 the systemic flow
 cardiac output which is in direct correlation to mortality
Abbas Ferdosi M.D.
Oct. 2014

Impella
Discharges directly to the Ventricle:

The pump pumps the blood from the LV

Resulting in a reduction of the wall voltage

Reduction of O 2 demand in the myocardium

While at the same time increases the O 2 supply
Regardless of the heart rhythm and catecholamines
Abbas Ferdosi M.D.
Oct. 2014

Physiological effect of Impella support
2
5
HCS-PP00022-004 rA EU
Abbas Ferdosi M.D.
Oct. 2014

Abbas Ferdosi M.D.
Impella® Controller (AIC)
Impella Controller (AIC) for monitoring and control of the Impella pump and the purge system.
Oct. 2014

Promotion of blood

The rotating drive sucks blood through the cannula

Impella controller (AIC) controls the rotation speed of the drive

The rotational speed is proportional to the flow

Faster rotation = Higher flow
Motor Impeller cannula
Oct. 2014

Impella
Impella
®
Circulatory Support Platforms
Flow Rate (L/min)
Circulatory Support
Catheter Size
Pump Size
Insertion Method
Impella 2.5
2.5
Partial
9 Fr
12 Fr
Percutaneous
Impella CP
3.7 – 4.0
Partial - High
9 Fr
14 Fr
Percutaneous
Impella 5.0
5.0
High-flow
9 Fr
21 Fr
Arterial Cut down
5.0
Impella LD
High-flow
9 Fr
21 Fr
Surgical Insertion
Abbas Ferdosi M.D.
Oct. 2014

Impella
Abbas Ferdosi M.D.
Oct. 2014

Myocardial Protection … O
2
Supply
Increased Myocardial Blood Flow, Aqel et al. (2009)
Blood Flow
(Coronary Arteries
& Microvasculature)
Aortic
Pressure
(AOP) a AOP
MR
Improvement in Myocardial Perfusion with Impella Support (Tc-99 MIBI
Imaging)
Impella OFF Impella ON
Abbas Ferdosi M.D.
Microvascular
Resistance (MR)
Under-perfused area
Impella increases perfusion
Oct. 2014

Myocardial Protection … O
2
Supply
Unloading Reduces Infarct Size…Impella vs IABP Meyns et al., JACC (2003)
Abbas Ferdosi M.D.
Oct. 2014

Circulation. 2012 Oct 2;126(14):1717-27.
10.1161/CIRCULATIONAHA.112.098194. Epub 2012 Aug 30.
A prospective, randomized clinical trial of hemodynamic support with
Impella 2.5 versus intra-aortic balloon pump in patients undergoing high-risk percutaneous coronary intervention: the PROTECT II study.
O'Neill WW 1 , Kleiman NS, Moses J, Henriques JP, Dixon S, Massaro J, Palacios I, Maini B, Mulukutla S, Dzavík V, Popma
J, Douglas PS, Ohman M.
CONCLUSIONS:
The 30-day incidence of major adverse events was not different for patients with
IABP or Impella 2.5 hemodynamic support. However, trends for improved outcomes were observed for Impella 2.5-supported patients at 90 days.
Abbas Ferdosi M.D.
Oct. 2014

Conclusion
Early mechanical support of the heart reduces mortality in cardiogenic shock.
Abbas Ferdosi M.D.
Oct. 2014

Abbas Ferdosi M.D.
Oct. 2014